21-hydroxylase deficiency medical therapy

Jump to navigation Jump to search

Congenital adrenal hyperplasia main page

Overview

Classification

21-hydroxylase deficiency
11β-hydroxylase deficiency
17 alpha-hydroxylase deficiency
3 beta-hydroxysteroid dehydrogenase deficiency
Cytochrome P450-oxidoreductase (POR) deficiency (ORD)
Lipoid congenital adrenal hyperplasia

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Overview

Medical treatment of 21-hydroxylase deficiency disorder depends on age: neonatal treatment is hydrocortisone or fludrocortisone as early as possible. If treatment cannot be started by 9 weeks, it should not be given at all. Surgical correction of ambiguous genitalia is the best treatment. Adults management: Hydrocortisone and Fludrocortisone acetate are the treatment of choice. CAH  patients need oral contraceptive pills to regulate the menstrual cycle and induction of ovulation.

Medical Therapy

Neonatal management

Prenatal diagnosis

Virilization of female fetus begins early; Therefore, early diagnosis and treatment are required as following :

  • Maternal administration of dexamethasone; in selected case of diagnosing prenatally. Dexamethasone crosses the placenta into the fetal circulation. And suppresses cosintropin in fetus.
  • This treatment should be started before nine weeks of pregnancy age; If treatment cannot be started by 9 weeks, it should not be given at all.
  • If in cell-free fetal DNA testing, male fetus detected, treatment should be discontinued.[1]
  • 85% of managed cases appear quite normal after delivery.[2]
  • Side effects of prenatal dexamethasone are:[3][4][5][6][7]   
    • Postnatal failure to thrive
    • Psychomotor developmental delay
    • Increased risk of cleft lip and palate
    • Increased risk for psychiatric disturbances and ADHD

Neonatal treatment

  • Hydrocortisone is 20 to 30 mg/m2/day divided in three doses 
  • Fludrocortisone 100 mcg twice daily 
  • One gram or 4 mEq/kg/day of sodium chloride divided in several doses 
  • One first time high doses of hydrocortisone, 50 mg/m2/day, can be used in order to suppress adrenal hormones.  
  • The minimization of steroid doses should be considered to avoid steroid complications. 
  • Growth suppression and shorter height in adulthood are the complications of using high d occurs in neonates treated with high doses of hydrocortisone.

Ambiguous genitalia 

  • The initial evaluation is pelvic ultrasonography to evaluate internal genitalia, karyotype for sex chromosome (SRY probe) material,
  • measurement of 17-hydroxyprogesterone and serum electrolytes. Until results release, glucocorticoid, mineralocorticoid and sodium chloride should be initiated
  • Girls with classic CAH typically undergo reconstructive surgery, usually clitoroplasty and vaginoplasty.

Adrenal crisis

  • 20 mL/kg of normal saline should be administered.
  • An intravenous bolus of 2 to 4 mL/kg of 10 percent dextrose should be considered if there is significant hypoglycemia.  
  • Hyperkalemia should be corrected with the administration of glucose and insulin if necessary.

Adults management

21-Hydroxylase

Glucocorticoids 
  • Glucocorticoids reduce the excess production of adrenal androgens and reduce the excessive secretion of both corticotropin-releasing hormone and  ACTH.
  • daily doses: hydrocortisone, a short-acting glucocorticoid, is the treatment of choice.
  • Dexamethasone a very potent and long-acting glucocorticoid effectively suppresses ACTH secretion but almost always causes the development of Cushingoid features with chronic use.[8]
  • Combination therapy, with typical doses of hydrocortisone to replace the cortisol deficiency during the day and a very small dose of a long-acting glucocorticoid. We suggest this approach when standard hydrocortisone regimens are ineffective.
  • Stress dosing: patients with classic 21OHD should be provided stress dosing.[9]

Mineralocorticoid replacement 

  • Fludrocortisone acetate, in a dose sufficient to restore normal serum potassium concentrations and plasma renin activity.[10]
  • The usual adult dose of fludrocortisone is 0.1 to 0.2 mg/day.[11]
  • Patients who are undertreated and in chronic poor control develop testicular adrenal rest tumors.
Infertility in men
  • Sperm production is often impaired in untreated men due to defected spermatogenesis and Leydig cells suppression.[12]
  • Most of the patients have severe oligospermia. Moreover, Most of the untreated patients have testicular tumors that need surgical removal.
  • An elevated FSH is a sensitive indicator for patients fertility condition but semen analysis is the specific test.[13]
Infertility in women
  • Lowering blood androgen levels helps women to control annoying cosmetic symptoms such as acne and hirsutism.
  • Similar to polycystic ovary syndrome, CAH  patients need oral contraceptive pills to regulate the menstrual cycle and induction of ovulation.[14]
  • Women need pregnancy should consult a surgeon to repair previous genital malformations.
  • hydrocortisone doesn’t pass placenta so, it can be used safely during pregnancy.
  • Glucocorticoids doses need to increase at end of pregnancy with careful monitoring.

11-Hydroxylase

Treatment is similar to 21-hydroxylase deficiency with glucocorticoid replacement. Clinical assessment of virilization, growth velocity, hair growth, menstrual function and blood pressure are necessary. Despite adequate glucocorticoid replacement, medication may be required to control blood pressure. Spironolactone is a good choice as well as calcium blockers.

References

  1. Bose KS, Sarma RH (1975). "Delineation of the intimate details of the backbone conformation of pyridine nucleotide coenzymes in aqueous solution". Biochem Biophys Res Commun. 66 (4): 1173–9. PMID 22237438 2 22237438 Check |pmid= value (help).
  2. Joint LWPES/ESPE CAH Working Group. (2002). "Consensus statement on 21-hydroxylase deficiency from the Lawson Wilkins Pediatric Endocrine Society and the European Society for Paediatric Endocrinology". J Clin Endocrinol Metab. 87 (9): 4048–53. doi:10.1210/jc.2002-020611. PMID 12213842.
  3. Speiser PW, Azziz R, Baskin LS, Ghizzoni L, Hensle TW, Merke DP; et al. (2010). "Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline". J Clin Endocrinol Metab. 95 (9): 4133–60. doi:10.1210/jc.2009-2631. PMC 2936060. PMID 20823466.
  4. Lajic S, Wedell A, Bui TH, Ritzén EM, Holst M (1998). "Long-term somatic follow-up of prenatally treated children with congenital adrenal hyperplasia". J Clin Endocrinol Metab. 83 (11): 3872–80. doi:10.1210/jcem.83.11.5233. PMID 9814461.
  5. Carmichael SL, Shaw GM, Ma C, Werler MM, Rasmussen SA, Lammer EJ; et al. (2007). "Maternal corticosteroid use and orofacial clefts". Am J Obstet Gynecol. 197 (6): 585.e1–7, discussion 683-4, e1–7. doi:10.1016/j.ajog.2007.05.046. PMID 18060943.
  6. Wallensteen L, Zimmermann M, Thomsen Sandberg M, Gezelius A, Nordenström A, Hirvikoski T; et al. (2016). "Sex-Dimorphic Effects of Prenatal Treatment With Dexamethasone". J Clin Endocrinol Metab. 101 (10): 3838–3846. doi:10.1210/jc.2016-1543. PMID 27482827.
  7. Khalife N, Glover V, Taanila A, Ebeling H, Järvelin MR, Rodriguez A (2013). "Prenatal glucocorticoid treatment and later mental health in children and adolescents". PLoS One. 8 (11): e81394. doi:10.1371/journal.pone.0081394. PMC 3838350. PMID 24278432.
  8. Horrocks PM, London DR (1987). "Effects of long term dexamethasone treatment in adult patients with congenital adrenal hyperplasia". Clin Endocrinol (Oxf). 27 (6): 635–42. PMID 2843311.
  9. Stewart PM, Biller BM, Marelli C, Gunnarsson C, Ryan MP, Johannsson G (2016). "Exploring Inpatient Hospitalizations and Morbidity in Patients With Adrenal Insufficiency". J Clin Endocrinol Metab. 101 (12): 4843–4850. doi:10.1210/jc.2016-2221. PMID 27623069.
  10. Speiser PW, Azziz R, Baskin LS, Ghizzoni L, Hensle TW, Merke DP; et al. (2010). "Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline". J Clin Endocrinol Metab. 95 (9): 4133–60. doi:10.1210/jc.2009-2631. PMC 2936060. PMID 20823466.
  11. Hughes IA (1988). "Management of congenital adrenal hyperplasia". Arch Dis Child. 63 (11): 1399–404. PMC 1779155. PMID 3060026.
  12. Reisch N, Flade L, Scherr M, Rottenkolber M, Pedrosa Gil F, Bidlingmaier M; et al. (2009). "High prevalence of reduced fecundity in men with congenital adrenal hyperplasia". J Clin Endocrinol Metab. 94 (5): 1665–70. doi:10.1210/jc.2008-1414. PMID 19258407.
  13. Claahsen-van der Grinten HL, Otten BJ, Takahashi S, Meuleman EJ, Hulsbergen-van de Kaa C, Sweep FC; et al. (2007). "Testicular adrenal rest tumors in adult males with congenital adrenal hyperplasia: evaluation of pituitary-gonadal function before and after successful testis-sparing surgery in eight patients". J Clin Endocrinol Metab. 92 (2): 612–5. doi:10.1210/jc.2006-1311. PMID 17090637.
  14. Casteràs A, De Silva P, Rumsby G, Conway GS (2009). "Reassessing fecundity in women with classical congenital adrenal hyperplasia (CAH): normal pregnancy rate but reduced fertility rate". Clin Endocrinol (Oxf). 70 (6): 833–7. doi:10.1111/j.1365-2265.2009.03563.x. PMID 19250265.